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f� App tions Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> '° " APPLICATION <br /> �s T" (For Non-Transferable;Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is he e1�tade rrypn b ess in the jurisdictional area of the San Joaquin Local Hea District <br /> ,F Business Name BA) ---------Address 7 ', <br /> z Owner Address <br /> a ;r. <br /> V Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.: Emergency Telephone Na. <br /> J Contractor Licence No. : <br /> _� <br /> L Applicants Name (Print) ,5',/ Title' Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information , pt' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - —Disposal Sites -A <br /> 'Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD .'* <br /> For July 1, June 30, 19 . <br /> -No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3.-El PERCOLATION TEST <br /> R.S. Or R.C.E. Name R.S. or R.C.E. No. <br /> Test�Location Test Date/Time <br /> 4.Kyr��SANITATION PERMIT <br /> Job Address/Location - � <br /> Ownerf ' Addresses <br /> JO-SEPTIC TANK ❑ CESSPO L �^L'EACHING FIELD OSEEPAGE PIT ❑ PACKAGE PLANT <br /> -PERMANENT ❑ TEMPORARY NEW ❑ REPAIR .9 OTHER <br /> 5. ❑ CHEMICAL'TOILETS -For July 1,"'June 30, 19 <br /> Type Construction Disposal Site- ' <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 5 <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified "^ U <br /> W <br /> Plant Location I <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 , <br /> SIZE ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r f <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 I hereby certify that I have pre a ed this plication and tha the work will be done in accordance'with San Joaquin County <br /> ordinances, stale laws, and le I i dation a San oaquin al Health District. <br /> APPLICANT'S SIGNATURE X <br /> 03 <br /> . i <br /> FOR DEPARTMENT USE ONLY t_ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DAMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> b0 <br /> FEE 5Z . <br /> LESS <br /> PRORATION - V11 ' <br /> PLUS �~ <br /> PENALTY <br /> OTHER, X �� <br /> OTHER <br /> r� � sl�sl� I <br /> Received by - Date Receipt No. Permit No.' - I saluancl Date I Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 209 STOCKTON,CA 95201'- <br />